The Training of Obstetricians: a Resident's View
THE FUTURE OF OBSTETRICS AND GYNAECOLOGY: The Fundamental Right To
Practice and be Trained According to Conscience: An International Meeting
of Catholic Obstetricians and Gynaecologist
Organised by the World Federation of Catholic Medical Associations
(FIAMC) and by MaterCare International
Sponsored by the Pontifical Council for the Health Pastoral Care ROME, June
Reproduced with permission
To sum things up: difficulties exist in every
country and at different levels: within the professional body, political
reasons or on a personal level. So far we have been able to practice
according to our conscience most of the times and received good medical
training despite our objections. However, we had to make compromises - or at
least we felt that we had to do them - in some areas for practical reasons .
Susanne van der Velden: Thank you for the honour to give
a contribution to our meeting from the point of view of a resident. As I
continually discussed this subject with Dr. Hefter we decided to present our
In a first part Dr. Hefter will share some questions we are actually
faced with as residents and give some reflections about residents situations
in different countries.
Further I'll share some thoughts about conditions and options for the
future. First I want to introduce myself: Susanne van der Velden, I'm in the
5th year of residency, I'm working in Germany, living in the Netherlands.
Almut Hefter: My name is Almut Hefter. I attended
medical school in Germany and I am now in the 6th year of training in O&G.
The decision to enter the specialty became clear during my final year. O&G
had always been my favourite subject, but I was afraid of the difficulties
regarding termination. I learned that Dr. Ehmann does not prescribe the pill
and does not do sterilizations. This was a foreign but also challenging view
to me. To explore this issue I did part of my final year in Stans in his
department, where he patiently answered my questions. During this time it
became clear to me that the teaching of the Catholic Church on contraception
was true and although things were now even more difficult, I felt that O&G
is what I want to do.
I have worked in Germany, Stans and now three years in England. Contrary
to Dr. van der Velden I am happy to work in non-Christian hospitals as I
prefer large units. My consultants and colleagues only know part of my
objections, especially regarding contraception. Surprisingly none of the big
units I've worked in did abortions for social reasons, a fact I did not know
when applying for the job. This has been a great relief for me and a sign
for God's provision and mercy.
What is the actual training situation in the different counties?
Firstly Great Britain: The professional body is the Royal College of
Obstetricians and Gynaecologists and membership is mandatory to work as a
consultant or specialist registrar. The College runs a structured training
program for registrars and places are very limited. The training program
includes contraception and termination, but it is - at least on paper -
acknowledged that there might be conscientious objections to some of these
issues. So far, whenever I expressed objections to a procedure in theatre,
this was readily accepted.
Having said this, there are plenty of guidelines published by the Royal
College, which define standard practice and it is expected - especially for
trainees - that they are closely followed. This includes for example that
the contraceptive pill or Mirena-coil are recommended for certain medical
conditions or that termination of pregnancy has to be offered in a
non-directive manner. Within these guidelines there is a large bias on
evidence based medicine and alternate ways of treatment, which might be more
acceptable to a Catholic doctor or patient are often not accepted due to
lack of good quality studies. Also it is virtually impossible for me to
offer alternatives as I can't guarantee to see the patient at a follow-up
visit. Due to the structure of the NHS, most people attending antenatal or
gynaecologic clinics see a different doctor every time. More detailed
explanations are difficult as there is usually a tight time schedule. And
last not least it is the Consultant who is ultimately responsible for the
care of the patient and he can dictate me what to do.
Now to Switzerland: The entire training to become a specialist must be
done in Switzerland. One year of training must be done at a University
Hospital where it is nearly impossible to object to terminations. At present
there is a single post in the whole country that is suitable for a pro-life
The situation is even worse for midwifes; they are unable to enter
training at all if they are not prepared to take part in the care of women
undergoing termination of pregnancy. In Germany it is possible to obtain the
specialist degree without undertaking abortions, sterilizations, or, for
example, amniocentesis as these procedures are not explicitly required.
There is no fixed national training program and training in other countries
is accepted. But the working atmosphere is generally less tolerant and one
is more dependent on the good will of the registrars to receive training
than in other countries. Here we have both experienced difficulties and
hardships although this was not consciously linked to our Catholic beliefs.
True for all countries is that training posts are limited and there is
fierce competition. Frequent and busy night shifts lead to constant
tiredness and make it more difficult to reflect critically on our own
practice or to keep our own Catholic spirits up. You are tempted to give in
to mainstream. There is a special hardship for women as a hospital job and
family with children can only be combined with great difficulties.
To sum things up: difficulties exist in every country and at different
levels: within the professional body, political reasons or on a personal
level. So far we have been able to practice according to our conscience most
of the times and received good medical training despite our objections.
However, we had to make compromises - or at least we felt that we had to do
them - in some areas for practical reasons, for example assisting
sterilizations or signing the consent for or prescribed the pill for medical
reasons if directed by a senior colleague.
Now, during our training several questions have arisen for which we still
struggle for answers: Humanae Vitae admits that even for Christian
couples faithfulness to the teaching can be very difficult. Our patients
come from all walks in life and most of them do not share our belief and
can't find strength in prayer or are in tremendously difficult situations.
How can we show them the love of Christ and that we care for them when we
are than asking just another difficulty from them? Are we doing the second
step before the first one?
What exactly is the definition of a Catholic gynaecologist? Is there one?
Would he or she be allowed to prescribe the pill? Under which circumstances?
We have been given conflicting information even from moral theologians. And
how do we look at the pill or Mirena coil for medical indications? Further
suggestions for alternate treatments are welcome. We have come across
couples that were definitely unsuitable for natural family planning. What do
we offer them? To change their doctor? What do I do if my patient is
requesting generally accepted treatment to which I have conscientious
objections, but I am the only doctor who is able to do it? I just imagine a
patient coming for her fourth caesarean section with planned tubal ligation
in the middle of the night, contracting. What do I do? Place her under the
risk of a further operation in the future because I'm not happy doing it?
Please take these questions as an expression of how much we still
struggle despite our own belief in the truth of the Catholic teaching.
Susanne van der Velden: Dr. Hefter has pointed out that
there is a big and still growing number and variety of obstacles we as
Catholic gynaecologists and obstetricians are faced with.
This rising number of obstacles leads to the second problem: We're
concerned about the small number of young Catholic doctors choosing for
gynaecology. So there are two questions arising:
1) is there a future for Catholic gynaecologists, and
2) will there be future Catholic gynaecologists?
Personally I'm absolutely sure that there is a future for Catholic
gynaecologists and that there will be future colleagues. But in order to
achieve this aim there are several conditions we have to discuss.
I think the problem is not that there are no human resources. Although
there is a decline, there is still a number of Catholic students and doctors
who would like to choose for gynaecology. But most of them finally decide to
work in another specialty.
Asking why they do so, there are repeatedly these two reasons:
1. They are afraid about the struggles they may be
faced with, and
2. They do not really know what it means to be a
Considering this as a "diagnosis" of the problem I want to share some
proposals for treatments with you.
Someone thinking about becoming a Catholic gynaecologist needs help and
guiding in order to choose for this profession. He must know the medical and
ethical challenges of this job in order to be able for a free and definite
decision making. Of course this decision has to be renewed permanently, but
there has to be a first "yes".
Further, I consider it to be important to know exactly, "What is the
definition of a Catholic gynaecologist?" As Dr. Hefter pointed out, this
remains a very important question for us also after having made the
decision. In our society the terms "Catholic" and "gynaecology" seem to be
contradictory and impossible to combine. In order to stay a good Catholic,
it seems to be better not to become a gynaecologist and as a gynaecologist
it seems to be better not to be a Catholic. So I consider it to be important
to give a true and reliable definition of the whole term.
Further we have to ask ourselves: What can we do to make our job
attractive for young students and acquire more colleagues? How can we help
young doctors to make their choice for the Catholic way of practising
gynaecology and to pursue this way?
In a first step I propose to give a structure to already existing
training options. These should be analysed and listed for example by a
co-ordinating institution. This includes the following three aspects:
Make a sum-up of all already existing training
centres. There are possible training centres all over the world, Catholic or
Make a sum-up of all Catholic gynaecologists. This
could be done in co-operation for example with Catholic institutions,
medical associations or gynaecological boards.
Added to these two systematic sum-ups there should be
an analysis of the particular difficulties as well as advantages in the
different countries, as Dr. Hefter pointed out.
This Evaluation of all our actual resources would serve our own plans for
the future and - making it accessible to others - it could be a guideline
Most information I got derives from personal experiences or experiences I
heard from others occasionally.
In order to acquire new colleagues there is a second step which I
consider to be essential: Making our job popular - I exaggerate: wherever
possible and with all possible means. Some examples: There could be
information week-ends, contacts with Christian students groups or with
Christian communities n I already mentioned a list of all Catholic
gynaecologists: there could be national and international contact persons
from this list for interested students and colleagues. These contact persons
know the situation of their own country and could co-ordinate publicity. n
Creating accessible information - for example information folders or
advertising in Christian journals or medical journals.
I think we have to use all our knowledge and our imagination to get
access to young Catholic medical students, to make them curious and to give
them the possibility to think about gynaecology as an option for them.
The next step is to support these students to become able to make their
decision and also to give them good training options. Some suggestions could
Regular contact between Catholic gynaecologists. This
could be through local meetings or meetings as here. Another option for
regular contact also on a long distance could be the Internet. Why shouldn't
there be a virtual "journal" for Catholic gynaecologists and of course all
interested colleagues with training elements, for example, contributions
about medical and ethical questions, discussions, job offers and demands,
and so on ?
The second suggestion is to give everybody interested
access to existing training options - for example by the above mentioned
list of training centres.
Finally - and the question is urgent: Is there a
possibility of a combined medical and ethical training centre? Where could
it be? For whom would it be accessible?
To conclude: in the beginning I asked two questions: "Is there a future
of Catholic gynaecology?" and "Will there be future Catholic
gynaecologists?" I already gave the answer: yes, considering three
The first was: defining our job and making it popular
The second was: giving interested colleagues a good
medical and ethical training and personal encouragement
The third and last condition I didn't mention yet - I consider it to be
the most essential and the fundamental one: We need to have a positive view
about our profession as Catholic gynaecologists! Often we say:
"Sorry, I'm a Catholic, I don't do this or that, I'm not allowed to".
That's a poor testimony - and not attractive for any young student to
imitate. Why don't we say:
As gynaecologists we perform an important and
wonderful profession: we're supporting life from it's very beginning till
the birth, we're caring for women in different, often very important steps
of their life, sometimes till their death.
As Catholics - I prefer to say Christians - in our daily work we are the
first and immediate witnesses of the miracle of God's creation and of the
mystery of the transmission of life, discovering God's face in each of our
patients. I wish us all arising from this congress a profound renewal of
ourselves: that we re-discover the beauty of the profession God gave to us
and that we testimony it to others.